Named Insured: Policy Number: Effective: Policy Year From: To: Company Name: ACE American Insurance Company Premium: [ ] Included [ ] $ Due When Coverage Begins ACCIDENTAL DEATH AND DISMEMBERMENT & MEDICAL COVERAGE FORM PART I - INSURING AGREEMENTS TO INSURE those persons described in Schedule I, the Accident & Health Declarations, each herein called the covered person(s), and subject to all of the Exclusions, Provisions and other terms of this policy, against loss resulting from accidental bodily injuries which: 1. arise out of the hazards described in Schedule II and are sustained by the covered person(s) during the term of this policy, and 2. occur as a direct result of the injuries, and from no other cause are herein called "such injuries," to the extent provided herein. Forms attached to and forming part of this policy on its date of issue are: Title Schedule I: Schedule II: Covered Persons Description of Hazards Coverage A - Death, Dismemberment or Loss of Sight If within one year from the date of accident such injuries shall result in death of the covered person(s), dismemberment or loss of sight, the Company will pay for: Loss of Life or Two or more members.....the Principal Sum; Loss of Speech and Hearing..The Principal Sum; Loss of Speech or Hearing. One-half the Principal Sum; Loss of One Member One-half the Principal Sum; Thumb and Index Finger from the Same Hand....One-fourth the Principal Sum; Such payment shall be in addition to any other indemnity payable as of the date of loss, but only one amount, the larger applicable amount, shall be payable for all such losses resulting from one accident. IT 10 01 01 03 Page 1 of 7
The "Principal Sum" is the amount specified as such in the Declarations. "Member" shall mean a hand, foot, or eye. "Loss" shall mean, with respect to hands and feet, actual severance through or above wrist or ankle joints; with respect to eyes, entire and irrecoverable loss of sight. Loss of a thumb and index finger means complete severance through or above the metacarpophalangeal joints, (the joints between the fingers and the hand). EXTENDED COVERAGE RIDER We will pay benefits for a loss resulting from a covered accident for an employee age 70 and over as follows: AGE AT DATE OF LOSS BENEFIT AMOUNT BASED ON SELECTED PRINCIPAL SUM Less than 70 100% 70 74 65% 75 79 45% 80 84 30% 85 and over 20% All plan benefits that are based on the Employee s Principal Sum will be computed according to the schedule above. Premiums are based on the Selected Principal Sum prior to the reduction outlined above. A Selected Principal Sum means the Principal Sum stated in the Policy Schedule. Coverage B Accident and Sickness Medical Expense If bodily injury or sickness requires treatment of a covered person(s) by a legal qualified physician or surgeon, the Company will pay the covered person(s) expenses incurred in excess of the deductible amount of $50 per occurrence within fifty-two (52) weeks from the date of bodily injury or sickness for any of the services listed under this policy section which are recommended and approved by the attending physician or surgeon, but not to exceed the maximum benefit as set forth in the schedule, as the result of any one bodily injury or sickness. Covered Expenses All covered expenses are subject to the general exceptions and limitations and the pre-existing conditions, limitations and provisions. Certain covered expenses are also limited as described within this section. An expense is incurred on the date of the treatment, service or purchase. Covered expenses include only expenses incurred by the covered person(s) or any covered dependent for the following, to the extent that they are reasonable and customary: In Hospital Covered Expenses: A. Daily Room & Board in a hospital, but not more than hospital's most common semi-private room rate to a maximum of $400. per day. B. Confinement in an intensive care unit, payable in place of expenses covered in (1) above up to 2 times the daily room and board rate. C. All other necessary services and supplies furnished by a hospital for in-patient medical care treatment, except for professional services. IT 10 01 01 03 Page 2 of 7
D. Service and supplies furnished by an ambulatory surgical or medical center, except for professional services. E. Out-patient medical care and treatment furnished by a hospital within 24 hours after or in connection with a surgical operation except for professional service. F. Professional local ambulance service for transportation to the nearest hospital and from a hospital subject to a $250. maximum per occurrence. Surgical Covered Expenses: A. A surgical procedure performed by a physician. B. Anesthesia and its administration. Other Covered Expenses A. Medical care and treatment furnished by a physician as a result of bodily injury or sickness. B. Out-patient medical care and treatment furnished by a hospital or clinic. C. Radium therapy, x-ray treatments and examination, microscopic tests, or any lab tests or analysis made for diagnosis or treatment. D. Physiotherapy. E. A second surgical opinion. F. The following supplies while hospital confined or prescribed upon release from hospital confinement: 1. drugs and medicines which require the written prescription of a physician; 2. whole blood and blood components; 3. artificial limbs or eyes (not including replacement of these items); 4. casts, splints, trusses, crutches, and braces (not including replacement of these items or dental braces); 5. oxygen or rental of equipment for administration of oxygen; 6. rental of a wheel chair or hospital-type bed; and 7. rental of mechanical equipment for treatment of respiratory paralysis. General Exceptions and Limitations This policy section will not pay benefits for expenses incurred for any of the following: A. Hospital confinement, surgery, treatment. service or supply for which: 1. The charge is payable or reimbursable by or through a plan or program of any governmental agency; or IT 10 00 01 03 Page 3 of 7
2. Charges are not imposed against the covered person or a charge is made solely due to the existence of insurance. B. Expenses incurred which are reimbursable by Medicare Part A and Part B. If a covered person at any time was entitled to enroll in the Medicare program (including Part B) but did not do so, his or her benefits under the Group Policy will be reduced by any amount that would have been reimbursed by Medicare. C. Eye refractions, eyeglasses, contact lenses, or hearing aids or the fitting of eye glasses, contact lenses or hearing aids. D. Cosmetic or plastic surgery, except: 1. when necessary as a result of bodily injury or sickness occurring while the covered person is insured under the Policy; or 2. reconstructive surgery when such service is incidental to or follows surgery resulting from bodily injury or sickness; or E. Hospital confinement, care or treatment which is not recommended and approved by a physician. F. Treatment or care of a person by a physician, registered nurse or licensed practical nurse if the physician or nurse is a member of the covered person(s)'s immediate family or ordinarily resides with the covered person(s). G. Private Duty Nursing. H. Physical examinations, unless required because of sickness. I. Any care furnished to a newborn child, including hospital nursery expenses. J. Any medical expenses related to pregnancy, unless such expenses are incurred as a result of an emergency, then a maximum benefit of $2,000.00 will apply per pregnancy. K. Dental Expenses, unless the result of an accident to sound natural teeth, then the benefit is limited to $1,000. per accident. L. Expenses related to alcoholism, chemical dependency or drug addiction. M. Expenses for treatment of mental illness or nervous disorder. N. Expenses incurred during any trip taken for the purpose of obtaining medical care. O. Bodily Injury or sickness which results from or in the course of a covered person(s)s regular occupation for pay or profit. (This does not apply to corporate officer partner or sole proprietor who is not insured under Workers Compensation Employer s Liability Law or similar law). P. Bodily Injury or sickness for which a covered person(s) is entitled to benefits under Workers Compensation Law, Employer s Liability Law or similar law, whether such policy is in effect or not in effect; Q. Expenses for the treatment of a pre-existing condition except as provided herein. IT 10 01 01 03 Page 4 of 7
DEFINITIONS The term "hospital" as used in this policy or any rider attached hereto shall mean, except as may otherwise be provided, a hospital (other than an institution for the aged, chronically ill or convalescent resting or nursing homes) operated pursuant to law for the care and treatment of sick or injured persons with organized facilities for diagnosis and surgery and having 24-hour nursing service and medical supervision. The term "physician" as used in this policy or any rider attached hereto shall mean a doctor of medicine or a doctor of osteopathy licensed to render medical services as performed, however, such definition will exclude chiropractors and physiotherapists. The term "sickness" wherever used in this policy or any rider attached hereto shall mean sickness or disease of any kind contracted and commencing after the effective date of this policy and causing loss covered by this policy. COORDINATION OF BENEFITS If a covered person insured under this Policy is also insured under one or more of the following other plans providing medical benefits: (a) group insurance or any other arrangement of coverage for individuals in a group whether on an insured or uninsured basis, or (b) Blue Cross, Blue Shield or any other prepayment coverage, then the benefits payable with respect to him under this plan are subject to reduction so that the sum of the benefits payable under this plan and all other plans for expenses incurred for each disability will not exceed the total Allowable Expenses incurred during such period. Benefits payable under another plan include benefits which would have been payable had claim been duly made therefore. "Allowable Expense" means any necessary, reasonable and customary item of expense at least partially covered under one of the plans involved. For the purpose of Coordination of Benefits, the Company: A. may release to or obtain from any other organizations or individuals any claim information and any individual claiming benefits under this plan shall furnish the Company with any information which the Company may require; B. has the right, if any overpayment is made under this plan because of failure to report other coverage or other reasons, to recover such over payment from any individual or individuals to whom it was made. PRE-EXISTING CONDITIONS Pre-existing condition is defined as benefits for a condition which a covered person(s) receives treatment, incurs expense or receives a diagnosis from a Physician during 90 days prior to the date of injury or sickness. With respect to Pre-existing Conditions, benefits will be paid to a maximum of $500.00. PART II EXCLUSIONS This policy does not cover loss caused by or resulting from any one or more of the following: A. Intentionally self-inflicted injuries, suicide or any attempt thereat, while sane, or insane; B. Declared or undeclared war or any act thereof, participation in a riot, civil commotion, or police action or commission of a felony; C. Accident occurring while the covered person(s) is serving full-time active duty in the Armed Forces of any country or international authority (any premium paid to be returned by the Company pro-rata for any such period of full-time active duty); IT 10 00 01 03 Page 5 of 7
D. Illness, disease, pregnancy, childbirth, miscarriage, or any bacterial infection other than bacterial infection occurring in consequence of any accidental cut or wound, except as previously stated in Accident and Sickness & Medical Expense section; E. Travel or flight in any vehicle or device for: 1. navigation beyond the earth's atmosphere, or 2. aerial navigation; except to the extent such travel or flight is provided in Schedule II. F. Nuclear incidents of any kind or description. SCHEDULE I: COVERED PERSON(S) The insurance under this policy applies only to the group of covered persons described and only with respect to those coverages for which an amount is specified. The amount so specified shall apply to each covered person subject to all terms of the policy having reference thereto. Covered Person(s) (includes all persons coming within the scope of such descriptions at any time during the policy term): 1. North Americans, meaning "employees" who are citizens or legal permanent residents of the United States (including its territories and possessions.) 2. Third Country Nationals, meaning "employees" who are not citizens of the country of their, workplace and who are not described in 1. above. 3. Local Nationals - NOT COVERED "Employee" means anyone employed by the Insured including any voluntary worker. At your option, "employee" may include individuals who are independent contractors with whom you have a written contract in which you agree to provide them benefits. SCHEDULE II DESCRIPTION OF HAZARDS The hazards against which insurance is granted under this policy are: 24 HOUR BUSINESS TRAVEL PROTECTION Excluding Insured Owned or Leased Aircraft Injury sustained by a covered person(s) while on the business of the Insured and during the course of any bonafide trip made by the covered person(s). Such trips shall be deemed to commence when the covered person(s) leaves his residence or place of employment (whichever occurs last) on a trip which requires the covered person(s) to leave his country of permanent assignment and shall continue until such time the covered person(s) returns to his home or place of work (whichever occurs first) in his country of permanent assignment. IT 10 01 01 03 Page 6 of 7
Such insurance includes injury sustained during such trip while the covered person(s) is riding as a passenger (but not as a pilot, operator or member of the crew, or cabin attendant) in or on, boarding or alighting from: A. any civilian aircraft having a current and valid standard category airworthiness certificate, and operated by a pilot holding a current and valid medical certificate and pilot certificate with appropriate ratings authorizing him to pilot such aircraft; or B. any transport type aircraft operated by the Military Airlift Command (MAC) of the United States, or by the service of any duly constituted governmental authority of any other recognized country; provided that, this Hazard shall not apply while riding in or on, or boarding or alighting from, any civilian or military aircraft other than expressly described herein, unless previously consented to in writing by the company. It is understood and agreed that the term while on the business of the Insured includes Sojourn. Sojourn means personal trips taken by the covered person on vacation days, holidays, weekend days or business days: A. while on the business of the Insured; and B. not exceeding a total of fourteen days. ADDITIONAL EXCLUSIONS Such insurance as is afforded a covered person(s) does not apply to any loss caused by, contributed to or resulting from injury sustained while in or on, boarding or alighting from: A. any aircraft being used for or in connection with aerial photography, or any test or experimental purpose, unless previously consented to in writing by the Company; B. any aircraft when a special permit or waiver is required from the authority having jurisdiction over civil aviation, even though granted, unless previously consented to in writing by the Company; C. any aircraft owned, or under lease, and operated by the Insured (or an employee of the Insured) or a covered person(s) (or an employee or member of his household), unless previously consented to in writing by the Company. PAYMENT OF CLAIMS To Whom Paid - Benefits paid on account of a covered person(s) death will be paid as follows: A. to his spouse, if living; B. if not, in equal shares, to his living children; C. if there are none, in equal shares to his living parents; D. if there are none, in equal shares to his living brothers and sisters; E. if there are none, to his estate. IT 10 00 01 03 Page 7 of 7